Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: results in 60 patients

Vinzenz Smekal, Alexander Irenberger, Rene El Attal, Juergen Oberladstaetter, Dietmar Krappinger, Franz Kralinger
Injury 2011, 42 (4): 324-9

INTRODUCTION: Elastic stable intramedullary nailing (ESIN) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates, good cosmetic and functional results, restoration of clavicular length and fast return to daily activities. Recent studies, however, also report on higher complication rates and specific problems with the use of this technique. This prospective study compares ESIN with non-operative treatment of displaced mid-shaft clavicular fractures.

METHODS: Between December 2003 and August 2007, 120 patients volunteered to participate. Of these, 112 patients completed the study (60 in the operative and 52 in the non-operative group). Patients in the non-operative group were treated with a simple shoulder sling. In the operative group, intramedullary stabilisation was performed within 3 days of the trauma. Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length (100%). Radiographic union was assessed every 4 weeks on 20 degrees cephalad anteroposterior and posteroanterior radiographs of the clavicle. Constant shoulder scores and DASH scores (DASH, disabilities of the arm, shoulder and hand) were assessed at final follow-up after 2 years.

RESULTS: ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures. We were not able to restore clavicular length in comminuted fractures using ESIN. Functional outcome at a mean follow-up of 24 months (range: 22-27 months) was better in the operative group. Delayed union and non-union accounted for the majority of complications in the non-operative group. In the operative group, telescoping was the main complication, which occurred in complex fractures with severe post-traumatic shortening only.

CONCLUSION: We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union, non-union and symptomatic mal-union. We also recommend ESIN in comminuted fractures with moderate (< or = 7%) post-traumatic shortening, as they will heal with moderate shortening. In comminuted fractures with severe shortening, however, we recommend plate osteosynthesis in order to provide for stability, clavicular length and endosteal blood supply.

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